If the shoe fits ... leading into the second century at Wake Forest University School of Medicine. (Wake Forest Centennial).

"What's past is prologue."

William Shakespeare

The Tempest, Act II, Scene 1

We drive into the future using only our rearview mirror.

Marshall McLuhan 

HISTORY offers inspiration and insight; it can also be a distraction. Richard H. Dean, MD, president and CEO of Wake Forest University Health Sciences (WFUHS), respects the record but resists being bound by it.

"Our success as an academic medical center will hinge on how we respond to change in a competitive environment through the management of our assets as the major growth industry in our region," he said.

Clinical revenues no longer can sustain the research and education dimensions, asserts Dean. "In many ways, it's like treating the academic mission like the R and D component of a big company." R and D (research and development) is all about strategy--making choices, carving out niches of expertise, gaining market share. Much of the business of Wake Forest University School of Medicine will continue in a manner respectful of the educational tradition that has carried it into a second century. However, the most radical new element undoubtedly will be the impact of an increasingly competitive research environment that has transformed universities from simply generators of ideas to places where those ideas are patented, licensed, and turned into business ventures.

Dean is neither the first CEO of Wake Forest University School of Medicine nor the first surgeon to head the school, but he is the first to attain the role without initially holding the title of dean. He recently engineered a major reorganization to create WFUHS, a wholly owned, nonprofit subsidiary of the university that includes the school, One Technology Place in the downtown research park (Fig 1), 10 dialysis centers, Amos Cottage Rehabilitation Hospital, and co-ownership of Wake Forest University Baptist Behavioral Health.

The prologue to the school's second century resounds in the legend of the "miracle on Hawthorne Hill," which attests that Coy C. Carpenter, MD, dean from 1936 to 1963 and vice president for health affairs from 1963 to 1967, started with the financial equivalent of a shoestring and crafted a shoe to fit it. (1) Dean's challenge is no less formidable--to steer an enterprise with an annual budget now in excess of half a billion dollars through the rapids of the inevitable and repetitive changes that characterize health care in the United States.

Technologic innovation fueled much of the advancement in medicine in the 20th century. Biotechnology and bioengineering are hot topics--the state of North Carolina operates the Biotechnology Center at Research Triangle Park, and Wake Forest University School of Medicine and Virginia Polytechnic Institute and State University have partnered on a School of Bioengineering and Sciences opening in 2002.

The late Harold D. Green, MD, a physician as comfortable and productive in the laboratory as in the clinic, provided a harbinger of this movement as early as the 1940s at the Bowman Gray School of Medicine of Wake Forest College. Green was a physiologist as well as a clinician and was a pioneer in the study of blood flow by means of the electromagnetic flowmeter. The flowmeter, as developed and adapted during Green's tenure as chairman of the department of physiology and pharmacology, was a major factor in research in cardiovascular disease and contributed to the school's rise to prominence in that realm. It also led to the creation of an independent business venture, Carolina Medical Electronics (now Carolina Medical, Inc, in King, NC).

Green was honored by his former students and colleagues in 1983 through a publication of original papers, Vasomotor Tone and Venous Return, (2) in recognition of the research grant Green maintained for more than 30 years. One of the contributors, A. Ben Denison, PhD, described the evolution of Carolina Medical Electronics. As Bowman Gray researchers' success with the flowmeter gained notice around the country, it created a demand for the machine among other scientists. That demand could only be met through a separate enterprise, initially operated out of the basement of the home of one of the founding engineers.

... [T]he business expanded out of the basement and into one of a series of rented sections of store buildings [and] organized more formally under the name of Kiger-Dennard Associates, for the two men who started it. By this time the world was indeed ready for circulation research, and the business kept expanding to the point where it seemed appropriate to incorporate it under a name that carried a better connotation of the type of work the company was doing.... One time I mentioned to Dr. Green that he could take some satisfaction from the work in his department having been responsible for starting a new industry.... Maybe that is the best criterion for judging the value of a research laboratory: when research work done there has evolved into an accepted technique that may be sufficiently commonplace that it is no longer newsworthy. (2)

The flowmeter story is one Dean and others at Wake Forest University School of Medicine would gladly have repeated, with the exception that some of the revenue stream remain directed to replenish the pool of intellectual capital that fosters this innovation and entrepreneurship. Clinical medicine will continue to provide vital services, but the character of the community will be changed dynamically and primarily by the research engine for which WFUHS provides some of the highest octane fuel.

Sneak previews of the future are staged periodically at the Research and Connectivity Expo, which originated with the Office of Research at the school of medicine. Expo is a forum for exchanging and showcasing the intellectual capital that leads to new high-tech business ventures. There is an official name for it--technology asset management, or tech transfer for short. Spencer Lemons, who specializes in this area for WFUHS, said, "We leverage the research capabilities and expertise of Wake Forest University School of Medicine with local, national, and international companies to help create products that can potentially benefit the public."

The best and most successful example at Wake Forest since Green's flowmeter gave birth to Carolina Medical is the vacuum-assisted closure (VAC) device for healing wounds. Conceived and executed in the department of plastic and reconstructive surgery by Louis Argenta, MD, and Michael Morykwas, PhD, the VAC has achieved international distribution because it is so effective. The picture painted by tech transfer is alluring. Since 1999, Wake Forest has recorded 24 license and option agreements, $19.5 million in licensing revenue, 68 new invention disclosures, and 4 new start-up companies; issued 2.2 million shares of stock in 11 companies; qualified for 30 US patents; and reinvested $700,000 in new research.

One step toward more involvement in this arena by WFUHS was the purchase in 2001 of One Technology Place in downtown Winston-Salem. The new research facility complements the school of medicine's presence downtown with the department of physiology and pharmacology. The strategic vision is that as the school's research capability expands, there will be an economic ripple effect.

"One Technology Place is tangible evidence of our commitment to work in the community toward an economy grounded in research and technology, particularly biotechnology," said Dean.

To generate the first ripples, WFUHS is investing $67 million in research at the school. (3) The goals are ambitious--to climb among the top 25 medical schools in total National Institutes of Health (NIH) funding, and to rank within the top 30 academic medical centers in annual licensing revenue as reported by the Association of University Technology Managers. To put the NIH goal in perspective, Wake Forest has never ranked higher than 35th (of 125). In the 1970s, it averaged 59th; in the 1980s, 47th; and in the 1990s, 38th. Five other medical schools in the Southeast--Duke, University of Alabama at Birmingham, North Carolina, Vanderbilt, and Emory--all ranked in the top 25 in 1998. Wake Forest's steady climb toward a higher profile in research reached a new plateau in 2001, when outside support topped $100 million. Just under 80% of that total came through the NIH.

The plan, according to Dean, will emphasize research in aging, genomics, cancer, cardiovascular disease, pulmonary diseases, diabetes, and complementary (or integrative) medicine. About one third of the investment will be for capital expenditures to provide for much-needed infrastructure, especially laboratory space on the Bowman Gray campus (Fig 2) and downtown. There will be an enhanced role for the Office of Research and the Office of Technology Asset Management.

In coming decades, another way WFUHS will broaden its presence and scope is through strategic collaborations. The school of medicine has partnered with Virginia Polytechnic and State University School of Engineering to create a school of biomedical engineering that will have operational components at both campuses. In the genomics field, the Comprehensive Cancer Center of Wake Forest University has a collaborative agreement with Human Genome Sciences, Inc, to investigate potential interventions at the molecular level that could lead to improved anticancer pharmaceuticals.

Other areas demanding attention to expand the research enterprise include a small-animal transgenic facility; increased capacity in core research imaging technologies; and investment in supercomputing to support bioinformatics and bioengineering programs.

One coherent and consistent thread runs through this mosaic of a new corporate nomenclature, partnerships with other educational institutions and private companies, technology transfer initiatives, Research and Connectivity Expo, etc: Wake Forest University School of Medicine. In that sense, the past truly is prologue. The school is the incubator from which this hubbub of 21st century action germinates.

To gain a perspective on research in biomedicine as the primary agent of change in the school of medicine's second century, compare modem theoretical physics and cosmology. The deeper particle physicists probe toward the most fundamental building block of the universe, the larger the universe appears in the telescopes of astronomers. Similarly, the deeper scientists probe into the human genome and the molecular universe it governs, the wider the scope of possible applications to human illness--and health. The opportunities and the challenges are daunting.

How much demand does such an emphasis on research place upon the school? In 1941, when the medical school moved to Winston Salem and expanded to a 4-year curriculum, 11 of its 62 faculty (17%) were classified as basic scientists. Ten years later, the school's most noted scientist, Camillo Artom, was stretched so thin financially that he was reduced to essentially beg one of his funding agencies to reallocate a portion of a grant from technical support to personal income. Within a few years, the Ford Foundation expressed a concern for the health of private medical schools and distributed $90 million to 45 accredited institutions. The Winston-Salem Journal reported, "Recipients were to use the funds as temporary endowment for ten years for purposes other than research or construction. Bowman Gray received $1.6 million and all income from this source was used to improve salaries of faculty in the basic medical sciences." (4)

At the turn of the century, only 23% of the approximately 750 faculty were basic scientists. Almost 80% of the more than $100 million in outside research support comes from the NIH, and the overwhelming majority of that is delegated to work in the basic sciences. Dean acknowledges a conundrum surrounding the central role of NIH in the lives of US medical schools--that it is impossible to be nationally recognized without increasing NIH funding, yet the school cannot afford to be so focused on NIH that it misses other growth opportunities.

"We must focus on what I call bookends of care," he said. "That includes clinical research that prevents the arrival of disease as well as basic and applied research relative to the treatment of disease. It is fascinating that the more 'basic' science becomes the more immediate applicability it seems to have to clinical initiatives."

On August 13, 2002, Dean and Wake Forest University president, Thomas K. I-learn, Jr., gathered with Congressman Richard Burr; North Carolina Secretary of Commerce, Jim Fain; Winston-Salem mayor, Allen Joines; and Idealliance president, Bill Dean to announce a plan to expand the Piedmont Triad Research Park on Winston-Salem's near-east side by nearly tenfold, to a 180-acre regional biotechnology center anchored by a downtown campus of Wake Forest University School of Medicine (Fig 3).

Dean said the unveiling of the plan was a fitting commencement to the celebration of the school's centennial year. "We believe this unprecedented linkage of the school of medicine to the community will set the stage for our second century to match our first in growth and accomplishment and service to humankind."

No timetable has been established regarding specific components of the school that might join the department of physiology and pharmacology and the Physician Assistant Program downtown; however, Dean expects that it will comprise both basic and clinical research programs, as well as some medical education. Piedmont Triad Research Park currently hosts approximately 600 employees of 20 tenants, with a total payroll approaching $25 million. It is estimated that, when fully completed in 10 to 15 years, the expansion could generate up to 10,O00jobs, $5 million in annual property tax revenue, and as much as $2.5 billion in total economic impact for the region. The new venture will be a unique blend of academic medicine, private technology start-ups, and retail businesses and restaurants.

The Winston-Salem Journal singled out Dean, Hearn, and C. Douglas Maynard, MD (Fig 4), a 1959 graduate of Wake Forest University School of Medicine and member of the faculty for 37 years, much of it as chairman of the radiology department and then director of the division of radiologic sciences. Maynard is credited by many for recognizing the potential for long-term investment in technology research, both by the school and in the community. "Wake Forest University once again proves how inspired the decision was to recruit the institution to Winston-Salem," the paper stated in an editorial on the research park expansion plan. (5)

True to its heritage, Wake Forest University School of Medicine is not content to cloister the miracle on Hawthorne Hill in a traditional academic ivory tower. Rather, Dean and others among the university and community leadership team would prefer to honor Coy Carpenter's legacy by acknowledging "if the shoe fits.

References

(1.) Davis CS: Bowman Gray school: a medical miracle. Winston Salem Journal and Sentinel, Sept 10, 1961, p D1

(2.) Hutchins PM, Green HD: Vasomotor Tone and Venous Return. Winston-Salem, NC, Hunter Publishing Go, 1983, p 20

(3.) Greene K: wake Forest invests big in genetics. Wall Street Journal (Southeast Edition), Jan 19, 2000, p S1

(4.) Meads M: The Miracle on Hawthorne Hill: A History of the Medical Center of the Bowman Cray School of Medicine of Wake Forest University and the North Carolina Baptist Hospital. Winston-Salem, NC, Wake Forest University 1988, pp 60-61

(5.) Downtown research park (Editorial). Winston-Salem Journal, Aug 14, 2002

From the Office of Development and Alumni Affairs, Wake Forest University Baptist Medical Center, Winston-Salem, NC.

Reprint requests to Stephen McCollum, Wake Forest University Baptist Medical Center, Office of Development and Alumni Affairs, Medical Center Blvd, Winston-Salem, NC 27157-1021.